Student Information Student s Legal Name: (First, Middle, Last) Name child prefers to be called: Grade/Class: Child s Address: Gender: [ ] Male [ ] Female of Birth: Child s S.S. #: Ethnicity (Circle One): Hispanic African American Native American Asian Caucasian Other List any existing medical conditions, medication and/or special attention your child may require? Allergies: Special Instructions: Pediatrician s Name: Phone: ( ) Parent/Guardian Information Mother/Guardian First Name: M.I. Last Name: Address: Occupation: Home Phone: ( ) Employed By: Office Phone: ( ) Work Address: Work Hours: Cell Phone: ( ) Email: [ ] Custodial Parent (If married, mark both parents) Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other Father/Guardian First Name: M.I. Last Name: Address: Occupation: Home Phone: ( ) Employed By: Office Phone: ( ) Work Address: Work Hours: Cell Phone: ( ) Email: [ ] Custodial Parent (If married, mark both parents) Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other Custody Information Check all that apply: o Student lives with both parents o Parents are separated o Parents are divorced o Father is deceased o Mother is deceased o Joint custody is held between & o Custody arrangements have been court adjudicated. (If applicable, a notarized copy of such adjudication must be filed along with the application before enrolling the students.)
Authorized Pickup Persons: Please list three to five additional authorized people who you wish to pick up your child/children. 1 st Contact/Pick Up Name: Phone: This person is authorized to have unfettered access and may pick up my child at any time YES NO 2nd Contact/Pick Up Name: Phone: This person is authorized to have unfettered access and may pick up my child at any time YES NO 3rd Contact/Pick Up Name: Phone: This person is authorized to have unfettered access and may pick up my child at any time YES NO 4th Contact/Pick Up Name: Phone: This person is authorized to have unfettered access and may pick up my child at any time YES NO 5th Contact/Pick Up Name: Phone: This person is authorized to have unfettered access and may pick up my child at any time YES Emergency Contact: *If we cannot contact parents or guardians, emergency contacts will be called in case of illness or emergency.* First Person Name: Phone: This person is authorized to have unfettered access and may pick up my child at any time YES Second Person Name: Phone: This person is authorized to have unfettered access and may pick up my child at any time YES Parent/Guardian Signature : Emergency Medical Action and First Aid I,, parent of, do hearby request and give consent to Harvest Time Academy, or its duly appointed representative, for said child to receive such medical or surgical aid as may be deemed necessary and expedient by duly licensed or recognized physician or surgeon in case of emergency when the parents can t be reached. NO NO NO Parent/Guardian Name (please print) Parent/Guardian Signature Today s
Educational History School s Reason for Departure School s Reason for Departure Student Information What does your child like best about school? What does your child like least about school? What are your child s favorite hobbies or free-time activities? What do you believe is your child s greatest strength: Socially? Academically? Spiritually? What do you believe needs improvement in your child s development: Socially? Academically? Spiritually? Has/is/does the applicant: (Circle One) Yes/No Repeated a grade? If yes, what grade(s)? Name of school Yes/No Been suspended or expelled (or been recommended for suspension or expulsion) from any school for any reason? Yes/No Been denied admission to a school? If yes, please explain: Yes/No Been home-schooled? If yes, give dates, grade level(s), and curriculum used: Yes/No Had a clinical diagnosis of a learning disability, If yes, please explain: Yes/No Participated in regular, standardized achievement testing. Yes/No Been recommended for any special testing or services; whether or not that recommendation was followed? Explain circumstances: Yes/No Undergone psychiatric, emotional, or behavioral testing, treatment, or counseling. If yes, please explain Yes/No Been prescribed any behavior-modifying drugs. If yes, please include name(s) of medication(s): Yes/No Currently taking prescription medication(s)? If yes, please list and their purpose: Yes/No Sought help for or been diagnosed with mental or emotional instability? If yes, please explain: Yes/No Demonstrated negative social behavior (i.e. disrespect, fighting, name calling)? If yes, please explain: Yes/No Participated in advanced classes? If yes, in which area(s): *If the applicant has any physical limitation or chronic illnesses of which we should be aware, please explain. (You may attach a separate page explaining his/her special needs) ----------------------------------------------------------------------------------------------------------------------------- --------------- Notice of Nondiscriminatory Policy as to Students Harvest Time Academy admits students of any race, color, nationality, and ethnic origin to all rights, privileges, programs, and activities generally afforded or made available to students at the school. It does not discriminate on the basis of color, nationality, and/or ethnic origin in the administration of its educational policies, admissions policies, and/or school-administered programs. Note: This application does not assure admission. Once all paperwork is returned and the enrollment steps are completed, eligible candidates will be contacted and the tuition deposit will be due. When all forms are completed and received, and the tuition deposit is paid, a space will then be held for that student. Initially, acceptance is given on a provisional basis until records from the student s former school have been received and reviewed.
Parental Permissions I,, parent/guardian of (Please circle to indicate your preference) Give/Do Not Give Give/Do Not Give Give/Do Not Give Give/Do Not Give Permission for photography of my child for publicity purposes. Permission for my child to be transported by Harvest Time Academy from school to facility, for field trips, and in instances of emergency situations. Permission to access immunization records from Web IZ Ark Health Dept. or OSIIS Permission to use antibiotic ointments, hydrocortisone creams, lotions, sunscreen or chapstick if needed. Parent/Guardian Signature Tuition / Payment Information: Current Tuition Amount: [ ] Weekly [ ] Monthly [ ] Bi-annual [ ] Annual Please outline below whom is responsible for payment of tuition and fees. Please fill out if parents are divorced and split tuition payment or if tuition payment is the responsibility of an adult other than the parents listed above. I am applying for financial assistance. Yes No (Circle One) *Please attach a letter describing your financial need, why you want to attend Harvest Time Academy and how much you are able to pay. Additional Comments & Information: Is there is any other information that that would be helpful to our management and teaching staff? --------------------------------------------------------------------------------------------------------------------- I affirm that all information in this application is true and accurate to the best of my knowledge. I understand that providing false information or omission of pertinent information could be reason for rejection of the application or dismissal of my child at Harvest Time Academy. I also understand that I may be asked to provide additional written information. Signature: Father/Guardian Signature: Mother/Guardian Signature: : : Thank You!
Honor Code I will faithfully attend and participate in scheduled services at Harvest Time or a similar Bible-believing church. I will strive to discover my God-given talents, develop them fully, and devote those talents to a lifetime of learning, serving, and honoring God. I will honor God by keeping my heart, mind, and actions pure. I will refrain from the use of profanity, vulgarity, or any other type of writing, print material, images, or conversation, which is inappropriate for a Christ follower. I will not lie, steal, cheat or tolerate such activity. I will show respect for authority and submit myself to the teachers and administration of Harvest Time Academy, realizing that attendance at HTA is a privilege, not a right. My dress and appearance will comply with the dress code of HTA, and reflect Christian values. My relationship with other students will be based on Christ s love. I will show care and concern for others in my speech and my actions. I will support the Harvest Time Statement of Faith as it is applied to instruction throughout the curriculum. I will uphold this Honor Code the full twelve months of the year, both at school and outside of school. Harvest Time Academy Statement of Faith Please read the following beliefs held by Harvest Time and Harvest Time Academy and complete the information: We believe the Bible to be the only inspired, infallible, and authoritative Word of God. We believe in one God in three manifestations: Father, Son, and Holy Spirit. We believe in the deity of Jesus Christ, in His virgin birth, in His atoning death, His bodily resurrection, and His ascension to the right hand of the Father. We believe in evangelistic and missionary fervor and endeavor. We believe in salvation through the redeeming blood of Christ. We believe in water baptism by immersion. We believe the believer is kept by the power of God by faith unto salvation. We believe that divine healing is obtained on the basis of atonement. We believe in sanctification and holiness of heart and overcoming life as Scriptural requirements for the bride of Christ. We believe in the baptism of the Holy Spirit and the present ministry of the Spirit in and through the believer manifested in the five ministries as they are being restored in end-time revival, the gifts of the Spirit, and the fruit of the Spirit. We believe in Christ s personal return in power and great glory, in His reign, and everlasting dominion. We believe in the resurrection of both the saved and the lost; they that are saved unto resurrection of eternal life, and they that are lost unto resurrection of eternal punishment. We believe the Holy Bible is the final authority on all matters concerning conduct, lifestyle, and behavior. We believe in the priesthood of the individual believer and the use of their gifts to edify the local church body and that each is qualified or disqualified spiritually, morally, domestically and doctrinally based upon the Holy Bible. I have read and understand the Honor Code & Statement of Faith of Harvest Time. I understand that all classroom instruction, chapel services, devotions, and Bible curriculum will uphold this Honor Code & Statement of Faith, and I will support the instruction of HTA, which is aligned accordingly. Father/Guardian Signature Mother/Guardian Signature Student Signature Name of Church Student Attends: (Church Name) (City, State) (Pastor s Name) Student actively involved in (Department or area or service) o Attend one or more church(es) but not committed to one particular church. o Student has made a profession of faith in Jesus as Savior.
Permission to Release School Records ELEMENTARY ENROLLMENT APPLICATION Student Name Grade I grant permission to: Name of student s previous school To release a copy of my child s school record, including the following information: Report Card Official Administrative Record (name, address, DOB, grade level completed, grades, class standing, attendance). Standardized Test Achievement Scores Teacher and/or Counselor observations and comments Intelligence and aptitude test scores Medical records Psychological testing, diagnostic, and evaluation reports Any other information that would affect the student s ability to be successful at Harvest Time Academy which would include disciplinary and behavioral records Other Parent Signature Pastoral Recommendation This Pastoral Recommendation Form is to be filled out for every applicant by a member of the pastoral staff, the children s pastor, or the youth pastor who knows the applicant well. I release all such references from liability for any damage that may result from furnishing such evaluations of my child to Harvest Time Academy and I waive any right that I have to inspect the references provided on my child s behalf. Parent Signature How long has the applicant s family attended your church? Circle the level of participation that most describes this family: *rarely attends *occasionally attends *consistent attendance, but doesn t volunteer *consistently attends & volunteers Please circle the terms which best describe the applicant s attitude toward the church and its activities: optimistic pessimistic consistent respectful critical inconsistent enthusiastic passive Is the applicant s influence on his/her peers: positive negative neutral Please Circle One: *I recommend * I recommend with reservations *I do not recommend Name Phone Position Name of Church/Denomination/Address Signature
Fee Contract Child s Name: Parent s Name: Tuition Total: HT Discount Scholarship Type: Amt: Please select one of the following tuition payment plans. Full payment of by August 1 st. 2 Half year payments of due August 1 st and January 15 th. Monthly payments of due by the 1 st of each month Weekly payments of due every Friday of the month starting August 1 st & ending May 15th. *Please include if you are applying for the Harvest Time Discount and submit the application with the enrollment packet. Yes, I am applying for the HT Discount No, I am not applying for the HT Discount Notes or Special Instructions: Please read and initial the terms of Harvest Time Academy Tuition policy listed below. Student Withdrawal Policy If it becomes necessary to withdraw a student, parents must notify HTA in writing by completing a Withdrawal Form. Parents must also complete the appropriate forms indicating that all books and school property have been returned in good condition and that all financial obligations have been met. No records will be released to parents, or to any other school, until this process is complete. Tuition for the entire month is due for students attending any portion of the month of withdrawal. There is a $500 early withdrawal charge, for parents withdrawing between July and April. Continuous Enrollment Policy Continuous Enrollment means that HTA students will be automatically re-enrolled unless the office is told otherwise. Parents have until February 1st each year to notify Harvest Time Academy s Business Office of any changes for re-enrollment. All enrollment permissions, agreements, and financial contracts signed in the previous school year will apply to all years going forward. The non-refundable re-enrollment deposit for the following year will be automatically billed each year on February 1st. As stated in the withdraw policy, there is a $500 withdrawal fee for withdrawing after July 1st. I understand that I will incur a $25 late fee for every week I fall behind on my tuition payment. I understand that the deposit is non-refundable. I understand that there is a $500 withdrawal fee during the school year between July and April. I have read and understand the withdrawal policy, and tuition for the entire month is due for students attending any portion of the month. I understand that final payments must be received by the last day of school before academic records and reports will be released. I understand that if my child is not picked up by 3:30 he/she will be placed in our after school program (Character Kids). All registration fees and daily tuition charges will apply. I have read and understand the continuous enrollment policy. Parent Signature Business Administrator Signature
Name: Parents Names: Phone # Birthday: Class: Start : Enrollment Steps *All boxes to be completed before start date* Staff Initials Tour of Center Fee Contract signed and filed Pastor Recommendation Parent s ID s copied HT Membership Discount Form completed (if applicable) Authorized pick up form Passed out car tags and added to car tag list Emergency contacts filled out Parent authorization and medical action plan filled out Social Security Number Birth Certificate verified Immunization Record submitted or available on WebIZ Immunization Record entered into ProCare Previous school records received Special testing (if applicable) Legal Papers (if applicable) Permissions: field trips, photography, walks behind building Allergies: entered in ProCare, Posted in Kitchen and Classroom Character Kids enrollment form (if applicable) Child info sent to teachers Child schedule entered Billing Set up All information recorded in ProCare under Elementary Tracking Bloomz, Handbook, Tech Agreement, Child Custody, Continuous Enrollment Flame Gymnastics **Office Use Only** File Review: : Staff Initials: File Review: : Staff Initials: